Kilcara House Nursing Home, Kilcara, Duagh, Kerry

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Centre name: Kilcara House Nursing Home

Centre ID: OSV-0000241

Centre address:

Kilcara, Duagh, Kerry.

Telephone number: 068 45 377

Email address: Kilcarahouse@gmail.com

Type of centre: A Nursing Home as per Health (Nursing Homes) Act 1990

Registered provider: Mertonfield Limited

Provider Nominee: Noel Kneafsey

Lead inspector: Mary O'Mahony

Support inspector(s): Michelle O'Connor

Type of inspection Unannounced

Number of residents on the

date of inspection: 29

Number of vacancies on the

date of inspection: 6

Health Information and Quality Authority

Regulation Directorate

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About monitoring of compliance

The purpose of regulation in relation to designated centres is to safeguard vulnerable people of any age who are receiving residential care services. Regulation provides assurance to the public that people living in a designated centre are receiving a service that meets the requirements of quality standards which are underpinned by regulations. This process also seeks to ensure that the health, wellbeing and quality of life of people in residential care is promoted and protected. Regulation also has an important role in driving continuous improvement so that residents have better, safer lives.

The Health Information and Quality Authority has, among its functions under law, responsibility to regulate the quality of service provided in designated centres for children, dependent people and people with disabilities.

Regulation has two aspects:

▪ Registration: under Section 46(1) of the Health Act 2007 any person carrying on the business of a designated centre can only do so if the centre is registered under this Act and the person is its registered provider.

▪ Monitoring of compliance: the purpose of monitoring is to gather evidence on which to make judgments about the ongoing fitness of the registered provider and the provider’s compliance with the requirements and conditions of his/her registration.

Monitoring inspections take place to assess continuing compliance with the

regulations and standards. They can be announced or unannounced, at any time of day or night, and take place:

▪ to monitor compliance with regulations and standards

▪ to carry out thematic inspections in respect of specific outcomes

▪ following a change in circumstances; for example, following a notification to the Health Information and Quality Authority’s Regulation Directorate that a provider has appointed a new person in charge

▪ arising from a number of events including information affecting the safety or wellbeing of residents.

The findings of all monitoring inspections are set out under a maximum of 18

outcome statements. The outcomes inspected against are dependent on the purpose of the inspection. In contrast, thematic inspections focus in detail on one or more outcomes. This focused approach facilitates services to continuously improve and achieve improved outcomes for residents of designated centres.

Please note the definition of the following term used in reports:

responsive behaviour (how people with dementia or other conditions may

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Compliance with the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013, Health Act 2007 (Registration of Designated Centres for Older People) Regulations 2015 and the National Standards for Residential Care Settings for Older People in Ireland.

This inspection report sets out the findings of a monitoring inspection, the purpose of which was to monitor ongoing regulatory compliance. This monitoring inspection was un-announced and took place over 1 day(s).

The inspection took place over the following dates and times

From: To:

29 June 2017 09:15 29 June 2017 17:45

The table below sets out the outcomes that were inspected against on this inspection.

Outcome Our Judgment

Outcome 02: Governance and Management Compliant

Outcome 07: Safeguarding and Safety Substantially Compliant Outcome 08: Health and Safety and Risk

Management Substantially Compliant

Outcome 09: Medication Management Compliant

Outcome 10: Notification of Incidents Non Compliant - Moderate Outcome 11: Health and Social Care Needs Substantially Compliant Outcome 12: Safe and Suitable Premises Substantially Compliant Outcome 13: Complaints procedures Compliant

Outcome 16: Residents' Rights, Dignity and

Consultation Non Compliant - Moderate Outcome 18: Suitable Staffing Substantially Compliant

Summary of findings from this inspection

This inspection of Kilcara Nursing Home by the Health Information and Quality Authority (HIQA) was an unannounced inspection. As a result of finding of non- compliance with regulations on the previous registration renewal inspection, a follow-up inspection was carried out. This was done to ascertain if the required actions had been addressed to the satisfaction of the Chief Inspector, prior to a decision being made on whether or not conditions would be attached to the registration renewal. On the day of inspection there were 29 residents in the centre and six vacant beds.

During the inspection, inspectors met with residents, the provider, the person in charge, staff from various roles, kitchen and household staff. Inspectors reviewed documentation such as, the complaints log, the risk register, care plans, training records and the annual review of the quality and safety of care. A new person in charge had been appointed since the previous inspection. She was supported in the management of the centre by the deputy person in charge.

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documentation and quality management systems had been enhanced. Complaints were being addressed and responded to. There was evidence of individual resident's needs being addressed and allied health care professionals were involved in meeting residents' assessed needs.

The findings of this inspection were based on the regulatory requirements of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 and the HIQA National Standards for Residential Care Settings for Older People in Ireland, 2016. Further actions were required by the provider to ensure that the centre was in compliance with all the aforementioned statutory requirements. These were set out in the action plan at the end of this report.

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Compliance with Section 41(1)(c) of the Health Act 2007 and with the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013, Health Act 2007 (Registration of Designated Centres for Older People) Regulations 2015 and the National Standards for Residential Care Settings for Older People in Ireland.

Outcome 02: Governance and Management

The quality of care and experience of the residents are monitored and

developed on an ongoing basis. Effective management systems and sufficient resources are in place to ensure the delivery of safe, quality care services. There is a clearly defined management structure that identifies the lines of authority and accountability.

Theme:

Governance, Leadership and Management

Outstanding requirement(s) from previous inspection(s):

The action(s) required from the previous inspection were satisfactorily implemented.

Findings:

Effective management systems and sufficient resources were in place. There was a clearly defined management structure in place, that identified the lines of authority and accountability. A new person in charge had been appointed. Inspectors spoke with her in relation to staff supervision, audit and team meetings. Since the previous inspection the annual review of the quality and safety of care delivered to residents had been compiled. There was evidence of consultation with residents and their representatives. Minutes of residents' meetings were reviewed. Staff appraisals forms had been revised and these had been circulated to staff who were currently completing the 2017

appraisals. The person in charge stated that she had more work to do in her

management role as she had only taken up her post in April 2017. However, she was found to be responsive to regulations and was praised by management, staff and residents who spoke highly of her communication style and her interactions with them.

Judgment:

Compliant

Outcome 07: Safeguarding and Safety

Measures to protect residents being harmed or suffering abuse are in place and appropriate action is taken in response to allegations, disclosures or suspected abuse. Residents are provided with support that promotes a

positive approach to behaviour that challenges. A restraint-free environment is promoted.

Theme:

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Outstanding requirement(s) from previous inspection(s):

The action(s) required from the previous inspection were satisfactorily implemented.

Findings:

Policies and procedures were in place for the prevention of abuse which referenced best evidence practice. Elder abuse prevention training was carried out as part of staff

induction. Residents with whom inspectors spoke stated that they felt safe in the centre.

Systems were in place to safeguard residents' money. The provider outlined practices used to record financial transactions. The provider stated that fees were handled separately to personal money/belongings. The provider was a pension agent for one resident and appropriate authorisation was in place for this. He stated that receipts were provided which reflected payments made. However, inspectors found that these receipts were not itemised. The provider stated that he was currently liaising with the accountant for the centre in order to provide a more accessible and transparent money

management system. Personal money transactions were recorded in a lodgment book and signed by two staff members.

Residents with dementia were assessed for behaviour issues associated with the behaviour and psychological symptoms of dementia (BPSD) on admission, in line with centre policy. Strategies to de-escalate BPSD were outlined in residents' care plans where appropriate. Since the previous inspection staff had received training to update their knowledge and skills in this area of care.

Inspectors reviewed the use of restraint assessment forms, risk balance tools and restraint consent forms in residents' files. A restraint log was maintained. The provider stated that all staff employed in the centre had the required Garda Siochana vetting in place prior to commencement of employment.

As a result of findings on the previous inspection, training in appropriate, respectful communication had been provided for all staff.

Judgment:

Substantially Compliant

Outcome 08: Health and Safety and Risk Management

The health and safety of residents, visitors and staff is promoted and protected.

Theme:

Safe care and support

Outstanding requirement(s) from previous inspection(s):

The action(s) required from the previous inspection were satisfactorily implemented.

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Policies and procedures relating to health and safety and an up-to-date health and safety statement were in place. The risk management policy addressed the

requirements set out under regulation 26(1). Policies had been signed as having been read and understood by the majority of staff. The person in charge stated that there were a number of staff who were currently reading the relevant policy. Plans to address identified risks were recorded in a risk register which had been updated since the

previous inspection. However, inspectors formed the view that the nurses’ station required risk assessment as regards electrical socket capacity, heat generated from electrical equipment and the lack of an effective closing mechanism for the fire-safety office door.

All staff had participated in mandatory annual fire training and regularly practiced drills. Drill records had been augmented since the previous inspection to outline the actions taken during the drill, included details of the time period involved and methods used. However, a list of participants had not been recorded. In addition, emergency

evacuation, fire and first aid procedures which had been laminated and placed on walls had faded over time and were illegible. The provider was asked to replace these for resident and staff information. The emergency evacuation/ fire exit location map for residents, visitors and staff was only available in the office and the front porch of the centre. The provider undertook to provide appropriate maps in the upstairs level and other hallways in the centre.

Judgment:

Substantially Compliant

Outcome 09: Medication Management

Each resident is protected by the designated centre’s policies and procedures for medication management.

Theme:

Safe care and support

Outstanding requirement(s) from previous inspection(s):

The action(s) required from the previous inspection were satisfactorily implemented.

Findings:

The medication prescription sheets signed by the general practitioner (GP). Medicines for crushing were prescribed as such. The person in charge stated that medicines were reviewed on a three monthly basis by the GPs. Processes for medicines management had been audited since the previous inspection and staff had completed appropriate training. For example, medicines no longer in use were returned to pharmacy and the names of medicines on prescriptions and on administration sheets had been correlated by the pharmacist.

Medication that required refrigeration was stored appropriately. The centre was

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staff training and was available to speak with residents.

Judgment:

Compliant

Outcome 10: Notification of Incidents

A record of all incidents occurring in the designated centre is maintained and, where required, notified to the Chief Inspector.

Theme:

Safe care and support

Outstanding requirement(s) from previous inspection(s):

Some action(s) required from the previous inspection were not satisfactorily implemented.

Findings:

An accident, incident, near miss log was maintained in the designated centre. However, inspectors found that the outcome was not always recorded or the incident signed off as closed. A separate log was kept specifically in relation to falls. These were seen to have been discussed at monthly quality safety meetings in addition to providing audit and trending information.

One issue had not been notified to HIQA within the three day time frame required. However, this had been recorded and documented. The person in charge had

adequately addressed it and had taken steps to mitigate any risk to residents' privacy and dignity. Appropriate disciplinary action, updated training and policy reminders had been circulated. Inspectors requested that this notification would be submitted

retrospectively. This was done following the inspection.

Judgment:

Non Compliant - Moderate

Outcome 11: Health and Social Care Needs

Each resident’s wellbeing and welfare is maintained by a high standard of evidence-based nursing care and appropriate medical and allied health care. The arrangements to meet each resident’s assessed needs are set out in an individual care plan, that reflect his/her needs, interests and capacities, are drawn up with the involvement of the resident and reflect his/her changing needs and circumstances.

Theme:

Effective care and support

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Some action(s) required from the previous inspection were not satisfactorily implemented.

Findings:

Inspectors reviewed a number of residents' files and observed that residents had a comprehensive assessment and care plan in place to meet their needs. Care plans included a detailed profile of each resident. Residents and relatives, where appropriate, were involved in developing and reviewing the care plans.

Residents had access to allied health care professionals and inspectors saw that these had been accessed for residents. For example, inspectors found that the speech and language therapist and the palliative services had provided care to residents. However, similar to findings on the previous inspection there were a number of discrepancies in the care plan of one resident as regards the residents' nutrition and mobility needs which had been updated incorrectly.

Nutritional needs of residents were met by the provision of a varied diet and nutritional supplements, where required. Residents were seen to be afforded choice at mealtimes and this was confirmed by residents, relatives and by the kitchen staff.

Oral care assessments were carried out and dental referrals had been made for a

number of residents. Eye care consultations and chiropody treatment were documented, in the sample of care plans seen.

The environment around the rooms and hallways was stimulating with a variety of pictures and reminiscence objects to engage and interest residents.

Judgment:

Substantially Compliant

Outcome 12: Safe and Suitable Premises

The location, design and layout of the centre is suitable for its stated purpose and meets residents’ individual and collective needs in a comfortable and homely way. The premises, having regard to the needs of the residents,

conform to the matters set out in Schedule 6 of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013.

Theme:

Effective care and support

Outstanding requirement(s) from previous inspection(s):

Some action(s) required from the previous inspection were not satisfactorily implemented.

Findings:

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scenic, rural area and was freshly painted a bright yellow colour. There was a lift and back stairs available to the top floor of the building. There were 17 single bedrooms with en-suites, six twin bedrooms, three of which had en-suites and two three-bedded rooms which had shared toilet and shower facilities. The provider was asked to continually risk assess the space and dependency levels of residents in the three-bedded rooms to ensure that each resident's privacy and dignity was maintained at all times. There was an empty bed in each of the two three-bedded rooms at the time of inspection.

Handtowels and soap were available in all bathroom and toilet areas.

Similar to findings on the previous inspection, inspectors found that there was adequate private and communal space in the centre. There were three sitting rooms downstairs, an oratory and an interlinked dining room/conservatory area. The smokers' room in the centre had been tidied up since the previous inspection and the door from this room was now closed when in use. The centre was clean and generally in good repair. Inspectors saw evidence of a cleaning schedule for all areas. The kitchen was located in the centre of the home and was easily accessible to staff and residents.

Judgment:

Substantially Compliant

Outcome 13: Complaints procedures

The complaints of each resident, his/her family, advocate or representative, and visitors are listened to and acted upon and there is an effective appeals procedure.

Theme:

Person-centred care and support

Outstanding requirement(s) from previous inspection(s):

The action(s) required from the previous inspection were satisfactorily implemented.

Findings:

There was a policy in place in the centre for investigating and handling complaints. The complaints procedure was displayed in the main reception area. The person in charge informed inspectors that since the previous inspection complaints were discussed at quality management meetings and complaints were responded to promptly. Inspectors reviewed the complaints log. The satisfaction or not of complainants had been

documented. The statement of purpose and the residents' guide also contained details of the complaints procedure.

Staff and residents were aware of the complaints procedure. The name and contact details of a nominated independent appeals person and of the ombudsman were displayed for use in the event that a complainant was unhappy with the internal investigation.

Judgment:

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Outcome 16: Residents' Rights, Dignity and Consultation

Residents are consulted with and participate in the organisation of the centre. Each resident’s privacy and dignity is respected, including receiving visitors in private. He/she is facilitated to communicate and enabled to exercise choice and control over his/her life and to maximise his/her

independence. Each resident has opportunities to participate in meaningful activities, appropriate to his or her interests and preferences.

Theme:

Person-centred care and support

Outstanding requirement(s) from previous inspection(s):

Some action(s) required from the previous inspection were not satisfactorily implemented.

Findings:

Inspectors reviewed the minutes of residents' meetings and noted that concerns were addressed. A meeting was held on 25 May 2017 at which residents had expressed their satisfaction with the quality of the food and staff were reminded to support residents to access fluids. Inspectors were informed that there was an external suitably trained person available as an advocate for residents.

Mass was facilitated weekly. Most residents had unrestricted access to a safe outdoor patio area. According to the person in charge residents were enabled to access the external garden paths with staff and relatives. Appropriate seating was available in the garden areas and colourful flower pots were planted at the entrance to the centre which had been repainted in recent months.

Residents’ wishes were prioritised when planning activities. There were photographs on display which had been taken at birthday parties and other celebrations. There were a number of areas in the centre where residents could meet visitors in private.

There was a variety of activities available to residents in the centre which were

organised and facilitated by an activity coordinator. The person in charge stated that the weekly activity schedule included music, bingo, crafts, skittles, newspaper reading, religious activity, Sonas, and chair based exercise. During the inspection, staff members were seen to spend short periods of time with different groups of residents facilitating for example, a game of skittles, hand massage and reading. However, at the time of inspection the activity personnel were not available due to absence and illness and groups of residents were seen unattended for periods of time in the various sitting rooms. Inspectors found that the activity staff were still listed on the roster as assigned to activities on the day of inspection. The person in charge stated that other staff

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Since the previous inspection a resident who had a high level of care needs had been moved from a three-bedded room to a single room to enhance his privacy and dignity needs.

Judgment:

Non Compliant - Moderate

Outcome 18: Suitable Staffing

There are appropriate staff numbers and skill mix to meet the assessed needs of residents, and to the size and layout of the designated centre. Staff have up-to-date mandatory training and access to education and training to meet the needs of residents. All staff and volunteers are supervised on an

appropriate basis, and recruited, selected and vetted in accordance with best recruitment practice. The documents listed in Schedule 2 of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 are held in respect of each staff member.

Theme:

Workforce

Outstanding requirement(s) from previous inspection(s):

No actions were required from the previous inspection.

Findings:

As previously discussed inspectors found that the roster was not being updated on a daily basis with respect to staff on duty. This was discussed with the person in charge who amended the record.

Inspectors reviewed a selection of staff files and saw that staff were recruited, selected and vetted in accordance with best recruitment practice and in line with the

requirements of Schedule 2 of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013. All staff nurses had up-to-date registration with An Bord Altranais agus Cnáimhseachas na hÉireann.

Staff appraisals were stored in a separate folder. The person in charge had created a new template for 2017 which included; current and future duties, support and

development needs and work relationships. The first stage of this new process had commenced and new appraisals had been circulated to staff. Inspectors found that staff files did not contain details of correspondence or meetings in respect of disciplinary proceedings. However, the person in charge had introduced a new employee incident form, a copy of which was to be stored in the relevant staff file.

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Staff meetings were scheduled every two months with an emphasis on unresolved issues and proposed solutions. Minutes seen by inspectors indicated that topics such as, fire safety concerns, wedging of doors, communicating with respect, accidents and incidents, medications errors and complaints were discussed.

Judgment:

Substantially Compliant

Closing the Visit

At the close of the inspection a feedback meeting was held to report on the inspection findings.

Acknowledgements

The inspector wishes to acknowledge the cooperation and assistance of all the people who participated in the inspection.

Report Compiled by:

Mary O'Mahony

Inspector of Social Services Regulation Directorate

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Provider’s response to inspection report1

Centre name: Kilcara House Nursing Home

Centre ID: OSV-0000241

Date of inspection: 29/06/2017

Date of response: 26/07/2017

Requirements

This section sets out the actions that must be taken by the provider or person in charge to ensure compliance with the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 and the

National Quality Standards for Residential Care Settings for Older People in Ireland.

All registered providers should take note that failure to fulfil your legal obligations and/or failure to implement appropriate and timely action to address the non compliances identified in this action plan may result in enforcement action and/or prosecution, pursuant to the Health Act 2007, as amended, and

Regulations made thereunder.

Outcome 07: Safeguarding and Safety Theme:

Safe care and support

The Registered Provider is failing to comply with a regulatory requirement in the following respect:

Receipts were required to be itemised.

Financial records were required to be maintained in an accessible and transparent manner.

1. Action Required:

Under Regulation 08(1) you are required to: Take all reasonable measures to protect

1 The Authority reserves the right to edit responses received for reasons including: clarity; completeness; and,

compliance with legal norms.

Health Information and Quality Authority

Regulation Directorate

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residents from abuse.

Please state the actions you have taken or are planning to take:

The registered provider is currently liaising with his accountant to provide a more accessible and transparent money management system.

Proposed Timescale: 31/07/2017

Outcome 08: Health and Safety and Risk Management Theme:

Safe care and support

The Registered Provider is failing to comply with a regulatory requirement in the following respect:

The staff office required risk assessment as regards fire risks from electrical equipment and an inadequate closing system on the office fire-safe door in these circumstances

2. Action Required:

Under Regulation 26(1)(a) you are required to: Ensure that the risk management policy set out in Schedule 5 includes hazard identification and assessment of risks throughout the designated centre.

Please state the actions you have taken or are planning to take:

The office fire-safety door is closing properly.

A risk assessment with regard to fire risks from electrical equipment has been carried out on 6/07/2017.

Electrician has been contacted and work is to be finalised on 31/07/17

Proposed Timescale: 31/07/2017

Theme:

Safe care and support

The Registered Provider is failing to comply with a regulatory requirement in the following respect:

Emergency evacuation procedures were faded and required replacement.

Fire exit/evacuation maps were not available in the upstairs section and hallways of the centre.

3. Action Required:

Under Regulation 28(1)(e) you are required to: Ensure, by means of fire safety management and fire drills at suitable intervals, that the persons working at the

designated centre and residents are aware of the procedure to be followed in the case of fire.

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Emergency evacuation procedures have been replaced.

New fire exit/evacuation maps are been compiled and will be available upstairs and in all hallways.

Proposed Timescale: 26/07/2017

Outcome 10: Notification of Incidents Theme:

Safe care and support

The Person in Charge (PIC) is failing to comply with a regulatory requirement in the following respect:

One issue had not been notified to HIQA within the three day time frame required.

4. Action Required:

Under Regulation 31(1) you are required to: Give notice to the chief inspector in writing of the occurrence of any incident set out in paragraphs 7(1)(a) to (j) of Schedule 4 within 3 working days of its occurrence.

Please state the actions you have taken or are planning to take:

The PIC will ensure that all notifiable events are forwarded to HIQA within the required timeframe.

Proposed Timescale: 26/07/2017

Outcome 11: Health and Social Care Needs Theme:

Effective care and support

The Person in Charge (PIC) is failing to comply with a regulatory requirement in the following respect:

A review and update of one resident's care plan was seen to contain incorrect information.

5. Action Required:

Under Regulation 05(4) you are required to: Formally review, at intervals not exceeding 4 months, the care plan prepared under Regulation 5 (3) and, where necessary, revise it, after consultation with the resident concerned and where appropriate that resident’s family.

Please state the actions you have taken or are planning to take:

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Proposed Timescale: 06/07/2017

Outcome 12: Safe and Suitable Premises Theme:

Effective care and support

The Registered Provider is failing to comply with a regulatory requirement in the following respect:

The provider was asked to continually assess the needs of residents who were

accommodated in the three-bedded room to ensure that their care needs and mobility needs would be supported and promoted.

6. Action Required:

Under Regulation 17(2) you are required to: Provide premises which conform to the matters set out in Schedule 6, having regard to the needs of the residents of the designated centre.

Please state the actions you have taken or are planning to take:

The use of three-bedded rooms are continually being assessed. There are still two residents occupying both three bedded rooms. A risk assessment will be carried out prior to occupancy.

Proposed Timescale: 26/07/2017

Outcome 16: Residents' Rights, Dignity and Consultation Theme:

Person-centred care and support

The Registered Provider is failing to comply with a regulatory requirement in the following respect:

There were limited opportunities for residents to avail of the activity programme on the day of inspection as the staff members who were rostered to facilitate this were not available.

7. Action Required:

Under Regulation 09(2)(b) you are required to: Provide opportunities for residents to participate in activities in accordance with their interests and capacities.

Please state the actions you have taken or are planning to take:

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Proposed Timescale: 30/06/2017

Outcome 18: Suitable Staffing Theme:

Workforce

The Registered Provider is failing to comply with a regulatory requirement in the following respect:

The roster did not reflect the number of staff on duty on the day of inspection to attend to all aspects of residents' needs.

8. Action Required:

Under Regulation 15(1) you are required to: Ensure that the number and skill mix of staff is appropriate to the needs of the residents, assessed in accordance with

Regulation 5 and the size and layout of the designated centre.

Please state the actions you have taken or are planning to take:

Two HCAs were assigned to activity duties on the day of inspection.Their names were still on the roster even though unavailable. The provider will ensure that the

appropriate skill mix of staff to meet residents' needs is provided on a daily basis.

Figure

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References

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